From the time Edward Leroy Bennett entered the Howard County Detention Center -- saying he was withdrawing from a $100-a-day heroin habit -- jail officials had repeated warnings that the 31-year-old addict might pose a danger to himself.
They treated his symptoms with medication, but did not put him under close observation, in the jail's drug-abuse treatment unit or in its suicide-watch cell. Guards reportedly made jokes about his drug habit to his face.
A little more than a day later -- on Dec. 9 -- Mr. Bennett, from Southwest Baltimore, hanged himself with a bedsheet from a ceiling water sprinkler in his cell.
The suicide, the jail's second since 1991, only came to light because inmates wrote letters to the news media.
Howard jail officials say that they acted properly and that Mr. Bennett's suicide could not have been prevented. But the jail's staff failed to heed warning signals that he might be suicidal:
* When Mr. Bennett was taken to the jail Dec. 8, he told correctional officers and medical personnel he was withdrawing from a $100- to $150-a-day heroin habit and he had a history of paranoia, according to police reports.
* About 11 a.m. the next day, Mr. Bennett told inmate Kenneth Coffey he "was on the verge of tears" and, "I don't know if I'm going to make it." In an interview, Mr. Coffey told The Sun he passed this information to correctional officer Joshua Osiruphu'el. (Officials barred interviews with jail guards.)
* About 3:40 p.m. that day, Mr. Bennett fell or threw himself down the stairs of his cellblock, police and jail reports say. Medical staff called to the scene reported that Mr. Bennett was lying "in a fetal position" and shouting, "Get the bugs off me!" according to portions of a jail medical report read aloud to a Sun reporter by jail security supervisor McLindsey Hawkins. (Officials would not release jail medical reports.)
Officials then increased Mr. Bennett's dosage of Vistaril, a drug that combats withdrawal symptoms, and added another drug, clonidine, used for hypertension, a police report says. Guards also moved him from a second-floor cell to one on the ground floor, police and jail reports show.
* At 4 p.m., jail guards Osiruphu'el and Alex Jacobs warned a third guard, Anthony Ravenell, at a shift change "to keep a close eye on" Mr. Bennett because of the incident on the steps, a jail report says.
But no additional precautions were taken. According to police reports and interviews with inmates, guards even taunted Mr. Bennett about his drug habit, joking: "We're going to get you your dope."
Jail officials defend their treatment of Mr. Bennett, noting that neither he nor anyone else directly reported he was suicidal. "People are going to commit suicide in prison -- it happens," said James N. "Buck" Rollins, the Jessup jail's director. "We had no indication that [Mr. Bennett] was suicidal. We did nothing wrong."
But an international consultant on jail suicide prevention, Joseph R. Rowan of Minnesota, says "reasonably trained" correctional officers would have recognized the "substantial" warnings of Mr. Bennett's suicide.
"They should have considered him a high suicide risk," Mr. Rowan said. "In preventing suicides, you don't have to be a rocket scientist: Common sense prevails. The staff apparently did not heed that warning."
The jail kept Mr. Bennett in a regular cellblock where he was checked once per hour and at dinner -- not in its administrative segregation unit or its suicide-prevention cell, both places where he would have been checked at least every 15 minutes.
The jail also did not send him to its 28-bed drug unit, where inmates receive treatment for drug addiction after medical referral.
At 7:05 p.m. Dec. 9, a guard making routine rounds found Mr. Bennett hanging from a sprinkler head in his locked cell, alone. A police report says he had folded a mattress on the bed, stacked a folded blanket on top and then stood on both to reach the sprinkler, about 10 feet off the floor.
Mr. Bennett's suicide was not made public until weeks after his death. The day Mr. Bennett died, the jail director wrote a note about the incident and gave it to a shift commander in case reporters happened to call. But it did not become public until inmates wrote letters to local news media.
The Bennett family has hired a lawyer to investigate the death. Relatives are angry about what they see as the jail's failure to heed clear signs their son was suicidal.
"Once he went into their doors, he was their responsibility," said his mother, Charlotte Bennett, who said she was barred by police from viewing his body at Howard County General Hospital the night of his death. "I'm not saying they should have put him in a country club, but they should have done something."
But Mr. Rollins, the jail's director for the past five years and warden at the Maryland Penitentiary in Baltimore for three years before that, said: "You can look at this thing as a 'woulda, coulda, shoulda' thing. But we did what we normally do."
The jail director noted that jail officers on duty at the time of Mr. Bennett's suicide stated in reports that the inmate was in good spirits and ate his meals before his death.
"If my officers had done anything wrong," he said, "I would have disciplined them."
Mr. Rollins said that when Mr. Bennett arrived at the jail complaining of medical and emotional problems, guards immediately referred him to the jail's medical staff -- in this case, a nurse. "Medical determined [a prescription] was the treatment he needed," Mr. Rollins said.
The detention center's medical unit is run by National Health Services, a company based in New York City. Pete Klaver, the company's vice president, declined to comment last week.
Police reports do not indicate that the inmate ever saw a doctor at the jail. A doctor normally examines inmates Mondays, Wednesdays and Fridays. A psychiatrist also comes in once a week, Mr. Rollins said.
Mr. Bennett was not placed in the administrative segregation unit, which includes a special suicide-prevention cell. Written jail policy states that various kinds of inmate segregation should be used for an inmate who is "severely mentally retarded or emotionally disturbed and/or potentially suicidal" or who "presents a threat to himself or others."
Suicide prevention experts say those criteria should have applied to Mr. Bennett.
"When the Howard County officials say they didn't know [Mr. Bennett] was suicidal, that is a clear indication that they need to be trained," said Mr. Rowan, president of Criminal and Juvenile Justice International Inc., a nonprofit group in Roseville, Minn. "You've got to err on the side of caution."
Lindsay Hayes, assistant director of the National Center on Institutions and Alternatives in Mansfield, Mass., said jail officials should have given greater weight to Mr. Bennett's reported drug withdrawal problems.
"Most jail facilities do not put inmates going through withdrawal in general population," he said, adding that Mr. Bennett should have been on close watch for his first 48 to 72 hours in jail because of his withdrawal.
Mr. Bennett had a long history of drug abuse. A high school dropout, he began using cocaine in 1987 and gradually moved on to heroin, his mother said. By 1989, when Mr. Bennett began developing a criminal record of theft and drug charges, his father, Harley Bennett, had kicked him out of their Southwest Baltimore home.
His life deteriorated. Mr. Bennett's girlfriend -- the mother of his only child, a son -- married another man. Mr. Bennett's family doesn't know her married name or where she lives.
For a year -- until his Dec. 8 arrest on charges in the theft of scrap metal in North Laurel -- Mr. Bennett lived on the street.
In addition to the Howard charges, Baltimore County police wanted Mr. Bennett on automobile theft charges. He already was on probation in Baltimore County on drug and theft charges.
On the Saturday after Thanksgiving last year, Mr. Bennett voiced fears to a close friend, Edward Sanders III of Southwest Baltimore. "He expressed to me that he didn't think he would be able to go to jail again," Mr. Sanders said. "He definitely showed signs of depression."
Howard jail officers apparently did not notice these fears.
Suicide prevention standards set by the National Commission on Correctional Health Care call on jail staff to be aware of signs of potential suicide. They say jails' intake forms should include specific assessments of inmates' suicide risk.
The initial intake form used at the Howard Detention Center does not ask officers for such an assessment. It is unclear whether the jail's medical intake form asks for that assessment because Mr. Rollins would not release it.
This is the second suicide at the detention center since Mr. Rollins became director. Before the one in 1991, the 13-year-old facility had never had a suicide.
Nationally, the suicide rate in local jails has declined, which experts attribute to improved screening at intake and better trained correctional officers.
According to the federal Bureau of Justice Statistics, suicides in local jails fell from 129 per 100,000 inmates in 1983 to 54 per 100,000 in 1993. Suicides made up a third of all local jail deaths that year. In Maryland during 1993, 29 of 33 local jails reported total of three suicides. In earlier federal surveys -- done every five years -- Maryland local jails reported six suicides in 1988, three in 1983 and three in 1978.